Dr Kai Ruggeri and Tomas Folke talk to ecancer at the R4HC meeting about the challenges created by the influx of Syrian refugees in Lebanon at a time when they are trying to integrate mental health into primary care services.

They discuss their work alongside the Global Mental Health Lab in implementing interpersonal psychotherapy as part of healthcare services and the benefits of this approach in both the short and long term.

They conclude that this issue feeds into the global movement towards pushing mental health services as a local policy matter.

Transcript

KR: Under the R4HC grant one of the primary themes is the mental health theme and there are two major components to the mental health theme, one in Palestine and the other in Lebanon. Lebanon is where we’re particularly focussed; we’re working with the Ministry of Public Health, with people representing the national mental health programme along with colleagues from Columbia University’s Global Mental Health Lab. The real focus of the work is in a time when they’re trying to integrate mental health into primary care services in Lebanon they’re also dealing with a large influx of Syrian refugees and so there are a number of challenges they’re facing in terms of trying to update and improve their own mental health services and we are trying to contribute to that. We are focussed more on the behavioural policy side but our collaborators are largely clinical mental health experts.

TF: One of the main things is just what Kai just mentioned about the influx of Syrian refugees – there’s a very large proportion of Palestinian refugees there from earlier conflicts and the mental health system just doesn’t have capacity to deal with what’s going on there. There’s also a big set of private mental health clinics that are independent of the state and that means that there are a lot of different systems in place that aren’t very well coordinated and well integrated currently.

KR: The Lebanese Ministry of Public Health has really made an investment in trying to develop and build and to move into the next generation of the way they do mental health services. On the one hand this is really great because this influx and these challenges actually do create opportunities and they’re really getting out in front on that. Certainly they are to be commended on the forward thinking they have but there are a lot of challenges in it because it’s not just as simple as we’ve got a lot of new people and we need new systems and pathways, there’s emotional challenges there because there are histories between these populations, there are obviously research challenges. Where we’re really trying to make an impact, though, is to work with our colleagues from the Global Mental Health Lab in implementing what’s known as interpersonal psychotherapy which is the WHO recommended mental health programme for conflict affected settings. What we are trying to do is help work that in to the policy structures there in their healthcare services because at its core it is an evidence based care programme for mental health services and it itself generates data, generates evidence. By having that information the hope is that it will eventually deliver even better mental health services over time. So not just a near term thing dealing with the immediate issues but a longer term building of research capacity through these new centres that have been developed in Lebanon but also just generally in the integration of mental health services into primary care.

TF: This also fits into your point about context dependency. One of the key points of evidence based mental health is that it needs to be adjusted to the context. So just because it’s been validated somewhere in the world it does not mean you can take it and copy and paste it to a new context without doing some critical evaluation and really trying to help to build that capacity into the structures in Lebanon.

KR: While also recognising the other challenges that they’re facing is another part of it, that it’s not just about mental health in that country and there are many, many other things. Sure, there’s plenty of good ideas and opportunities or resources available that could be implemented but it’s not just that it doesn’t exist in a silo. You have to be not just contextually specific, you have to be daily specific because things change very quickly. The expression they have is sand runs faster than water, or something like this.

What have the main themes of the meeting been so far?

KR: Being more intentional with the way we engage people and interact with partners and really be more open in how we’re engaging beyond the immediate networks we already know about. I think somebody already said we look where we know to look but that doesn’t mean that’s where we should be looking. That’s a theme of today that will hopefully carry over in how the work is implemented in the next few years.

TF: Yes, definitely. And also just in terms of contextual knowledge. I think it’s so good to have these strong collaborations between academics in the region and academics who do global health and global mental health work in the UK and elsewhere to actually get more of that contextual embedding. It’s very hard to do good work without having that component.

KR: And I’d actually say a point maybe I left out – the people that really need to be recognised and committed are the people training these new mental health care practitioners, these providers, because in Lebanon you’re talking about community health workers, you’re talking about social workers. You’re not only talking about people who are clinically trained professionals in a clinical environment, you’re talking about people who are out in the community engaging people in all different sorts of contexts. Those are really the heart and soul of all of this because they are people who have committed to being trained and then implementing this for impacting mental health within their communities. Within the broader global movement to push mental health as a local policy matter, and it should be in all forms of local policy, those are really where the lifeblood of all of this runs through. Our team, our collaborators both in New York and in Beirut, they do all the real legwork in getting those people moving but then those are the people actually delivering it. That’s one thing we have to remain vigilant about is making sure we remember that at all times. We can have great research, academic discussions about policy and all these things but in the end it really does go back to those people who are on the ground from the region.

What training will be happening in the coming future?

KR: We’ve had a rolling start with that, our colleagues from the Global Mental Health Lab have started that. The intention is just to continue and move it. We’re at a piloting stage through the first year, a little beyond that, but I would say that as of now we’re intending to just do more of the same. Then the real big thing that they’re going to do is they’re going to come to the UK and train people in the UK to be able to then do that in more places. So the real intention is to not just impact in Lebanon but to get more people who are based in the UK trained in this WHO recommended approach and then go forth and make an impact in that way. So I’d say the plan is more just to get better at what we’re doing and then expand where and how it’s being done.

TF: Yes, and the key idea here really is cascading impact because then you have skilled scientist practitioners who can teach local trainers who in turn can teach local front line workers. So in that way you can hopefully leverage and reach many more people than you could if you just went down and held a week-long training or if you yourself tried to provide support. This is the beauty of capacity building – you can reach many more people than you could if you just tried to do something on your own.